Recurring concern

Failure to provide effective on-duty clinical leadership

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First reported 30 Aug 2013•Latest report 8 Feb 2024

Definition

What this concern includes

Includes failures of on-duty clinical leadership in clinical or care settings, including absent or unclear leadership, inability of the available leader to provide clinical direction or support, and inadequate leadership of ward or immediate-care operations.

Not included

Excludes generic organisational leadership or governance deficiencies that do not concern leadership of clinical care or clinical teams.
Excludes failures of senior review, consultant attendance, clinical supervision or staffing capacity where on-duty clinical leadership is not the shared unsafe condition.
Excludes leadership failures in non-clinical settings, such as race control, event management or custody operations, unless the assertion explicitly concerns leadership of clinical care.
Excludes isolated poor clinical decisions where no deficiency in the availability, clarity or effectiveness of on-duty clinical leadership is identified.

Reports: 15
Individual concerns: 17
Date range: 2013–2024
Stated actions: 12

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England4

Department of Health and Social Care3

Birmingham and Solihull Mental Health NHS Foundation Trust1

Care Quality Commission1

CSC Computer Sciences Limited1

Cwm Taf Morgannwg University Local Health Board1

Cygnet Health Care Limited1

General Medical Council1

Hellesdon Hospital1

Hull University Teaching Hospitals NHS Trust1

Isle of Wight NHS Trust1

James Paget University Hospitals NHS Foundation Trust1

Leeds and York Partnership NHS Foundation Trust1

Milton Keynes University Hospital1

NHS Surrey and Sussex Integrated Care Board1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

29 Sep2015
Milton Keynes
Concerns raised2
1. Lack of staff understanding of labour ward management associated with ineffective leadership
2. Lack of on-duty clinical leadership to provide advice, support and direction
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Establish a dedicated Labour Ward Matron role.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated completed
2. Action
  Establish a Maternity Unit Manager of the Day role.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated completed
3. Action
  Undertake joint leadership training for senior midwives and consultants.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated planned
1. Action
  Review the Consultant Midwife’s role in supporting clinical leadership on Labour Ward.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Leadership was appropriately allocated between concurrent emergencies, and the registrar was experienced enough to manage the delivery.
  Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concern
AI-generated summary

Ethan Robert Johnson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ethan Johnson was born following an urgent Caesarean section, with no respiratory effort or heart rate, and died after intensive care treatment was withdrawn. The concerns included a lack of effective leadership, support and escalation when an abnormal CTG was identified. The inquest concluded that delayed delivery resulted in a lost opportunity to deliver him earlier and provide further medical treatment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of staff understanding of labour ward management associated with ineffective leadership
Wider context from the report
“(5) There appeared to be a lack of understanding by members of staff as to labour ward management because of the lack of effective leadership. ”
Source location
Ethan Robert Johnson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of on-duty clinical leadership to provide advice, support and direction
Wider context from the report
“(4) No one on duty in the unit was able to assume the leadership role and be in a position to offer advice, support and to direct the course of events. ”
Source location
Ethan Robert Johnson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a dedicated Labour Ward Matron role.

Verbatim wording from the response
“A new, specifically dedicated Matron for Labour Ward has ensured that a revised handover communication tool (SBAR) is embedded in practice, so that a succinct common language is in place to enable the medical staff to make an appropriate assessment of when to attend. There is now a Manager of the Day on the Maternity Unit.”

Source location
2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
Page 2 · response
Published 29 September 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish a Maternity Unit Manager of the Day role.

Verbatim wording from the response
“A new, specifically dedicated Matron for Labour Ward has ensured that a revised handover communication tool (SBAR) is embedded in practice, so that a succinct common language is in place to enable the medical staff to make an appropriate assessment of when to attend. There is now a Manager of the Day on the Maternity Unit.”

Source location
2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
Page 2 · response
Published 29 September 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Undertake joint leadership training for senior midwives and consultants.

Verbatim wording from the response
“Joint leadership training for Senior Midwives and Consultants will be undertaken in January 2016 which will further strengthen multidisciplinary team-working.”

Source location
2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
Page 3 · response
Published 29 September 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the Consultant Midwife’s role in supporting clinical leadership on Labour Ward.

Verbatim wording from the response
“We are also currently reviewing of role of our Consultant Midwife in terms of supporting clinical leadership on Labour Ward.”

Source location
2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
Page 3 · response
Published 29 September 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Leadership was appropriately allocated between concurrent emergencies, and the registrar was experienced enough to manage the delivery.

Verbatim wording from the response
“████████ arrived on delivery suite at 13.10 hours, monitoring was commenced at 13.13 hours, and concerns became apparent with the acute fetal bradycardia (low heart rate) at 13.25 hours when ████████ (Consultant) was already on delivery suite managing a separate maternal emergency. At this point he directed ████████ (the Registrar) to deal with ████████ in the first instance and the appropriate management plan was carried out by taking her immediately to theatre to expedite delivery of the baby.”

Source location
2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
Page 2 · response
Published 29 September 2015
Open published response
23 Jul2015
Birmingham and Solihull
Concerns raised1
1. Lack of clear ward leadership
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Birmingham Cross City CCG commissions the service and is undertaking work to address the identified care deficiencies.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Doreen England · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Doreen England, an 81-year-old woman with vascular dementia, developed a severe pressure sore during her admission to Rosemary Suite from 20 July 2014 and died on 30 September 2014. The principal concerns were the failure to prepare and implement a care plan despite her high risk, inadequate staff knowledge and training about pressure sore prevention, and insufficient ward leadership and medical cover.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clear ward leadership
Wider context from the report
“(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover. ”
Source location
Doreen England · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Birmingham Cross City CCG commissions the service and is undertaking work to address the identified care deficiencies.

Verbatim wording from the response
“It is also a significant concern that at the time of the inquest the organisation involved does not appear to have responded in correcting these issues. We are in communication with Birmingham Cross City CCG which has undertaken a significant amount of work in relation to this case already and who commission the service and will also ensure CQC are aware of the case.”

Source location
2015-0291-Responses
Page 7 · response
Published 23 July 2015
Open published response
1 Jun2015
Inner North London
Concerns raised1
1. Lack of clinical direction in crisis care
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.
  Stated by North London NHS Foundation TrustStated completed
AI-generated summary

Mark Patrick DANIELS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mark Patrick Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. The principal concerns were failures to carry out and record planned visits, communicate within the team and with crisis houses, progress a crisis-house referral promptly, and consider hospital admission despite identified suicide risk and Mr Daniels stating that he did not feel safe at home.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clinical direction in crisis care
Wider context from the report
“You will see from the determination attached, that I found there was a failure by the crisis team: - to visit Mr Daniels twice a day, despite a plan so to do; - to record why twice daily visits were not attempted; - to communicate within the team and with the two crisis houses; - to progress the referral to a crisis house promptly; - to consider hospital admission, despite the fact that Mr Daniels was known to have made several suicide attempts; had told staff he did not feel safe at home; was observed to be keeping a rope at home; told staff he would kill himself, albeit not immediately; said he wanted to be in a contained environment; and there was apparently no prospect of prompt admission to crisis house. I gained the impression of a lack of cohesion and clinical direction. ”
Source location
Mark Patrick DANIELS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement measures across all Crisis Teams and Crisis Houses to address the identified concerns.

Verbatim wording from the response
“████████ Associate Divisional Director for the Acute division has considered your concerns and put in place a comprehensive action plan to address them – the action plan is appended at the end of this letter. As you can see from the action plan updates, several”

Source location
2015-0208-Response-by-Camden-and-Islington-NHS-Trust
Page 1 · response
Published 1 June 2015
Open published response
1 Sep2014
Inner North London
Concerns raised1
1. Lack of clarity of ward leadership and support
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Thomas Charles TAYLOR · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clarity of ward leadership and support
Wider context from the report
“1. The ward where Mr Taylor was being nursed seemed rudderless, operating without clarity of leadership or support. On 21 February, a bank nurse worked alone in the morning, though was joined by another agency nurse at lunch time, with only a senior nurse in the office. On 22 February, the nurse in charge appeared unclear that he had any additional responsibility by virtue of being the nurse in charge, other than to allocate nurses to patients. Despite only three nurses being on duty on 22 February, the nurse in charge took a break at the same time as another nurse. There was a conflict of views among the nurses that day about who had primary care of Mr Taylor. ”
Source location
Thomas Charles TAYLOR · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Aug2013
South Lincolnshire
Concerns raised1
1. Lack of consultant leadership of immediate care
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Jessica Florence Ashton-Pyatt · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jessica Florence Ashton-Pyatt became acutely unwell on 28 October 2012 and died after unsuccessful resuscitation following admission to hospital. Concerns included unco-ordinated care, initially absent consultant leadership, an uncharged defibrillator, and no defibrillation pads initially being available.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of consultant leadership of immediate care
Wider context from the report
“The response of the staff to Jessica's care on admission was unco-ordinated, with the immediate care being delivered by an SpR in anaesthetics and two EMAS paramedics. There was initially no consultant leadership of Jessica's care. The defibrillator in the resuscitation bay was not charged and no defibrillation pads were initially available. ”
Source location
Jessica Florence Ashton-Pyatt · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of staff understanding of labour ward management associated with ineffective leadership

Lack of on-duty clinical leadership to provide advice, support and direction

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of clear ward leadership

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of clinical direction in crisis care

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Lack of clarity of ward leadership and support

Concerns raised1

Lack of consultant leadership of immediate care

Actions described in response 4

Respondent positions 1

Respondent positions 1

Actions described in response 1